197609720-5-11-2024-31-AS-MCAA-D56TKE-20240511144748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 05/11/2024
Date Signed: 05/11/2024 02:48:41 PM

Document Has Been Signed on 05/11/2024 02:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	KAREN MARIN		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 89	DATE:	05/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Christine Ellis		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the community sales director, Christine Ellis and explained the reason for the visit. At approximately 09:30am, with the assistance of the community sales director and maintenance staff, LPAs took a tour of the physical plant. The facility is a two story building. The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. Smoke alarms were last inspected on 04/03/24. Facility also have a functional sprinkler system. There are fire extinguishers located throughout the facility hallways. The charge date for the fire extinguishers was 05/02/24 and pull system. Fire drill was last held 04/02/24. Kitchen: The kitchen is commercial. Appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food properly stored. Bedrooms: The facility is two stories, with resident bedrooms on both the first and second floors. Random rooms were inspected on both floors, and LPAs observed appropriate beddings and linens with sufficient lighting. Bathrooms: Each resident unit on both floors have their own bathrooms. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was between 113.4 to 118 degrees Fahrenheit. No cleaning supplies observed stored in resident bathrooms. Common Areas: These include the lobby, activity area, theater, bistro, beauty shop (on second floor), library (also on second floor), and dining area. The common areas were properly furnished, observed to be in repair. Floors were mopped and clean. Hallways and passageways are free of obstruction. Elevators, two (2), were functional.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE	FACILITY NUMBER: 197609720
	VISIT DATE: 05/11/2024

NARRATIVE

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Surrounding Grounds: There is a memory care, with twelve (12) rooms and and a total of eighteen (18) beds. Delayed egress was tested and is functional. Outside of the memory care, there is an enclosed courtyard with open space Gazebo. Exterior door/perimeter fence, cleared. Hallways in the assisted living area, on the first and second floor were inspected and observed free of obstruction. Outside area of the assisted living also has a gazebo, with patio furniture, appropriate for outdoor use.

Laundry Room: There are three laundry rooms. One commercial laundry room is located on the first floor, besides the medication room. There are two smaller laundry rooms located on the second floor, for resident use. The commercial laundry room is kept locked. The two smaller laundry rooms have resident access, but no detergents or cleaning supplies accessible. Residents who wish to do their laundry, are to bring their own.

Resident Files: Resident files are maintained in the medication room. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are maintained at the business office. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication Room is located on the first floor, in between the memory care unit and assisted living. There were three medication carts and electronic MARS. Random review of resident medications and medication records were made for proper documentation. Medication room is locked at all times.

Office/Work Station: The administrator's office and sales and marketing room is located near the front entrance, near the front desk, where LPA's checked in with the receptionist.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024

LIC809 (FAS) - (06/04)

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